• Broad agreement regarding evidence demonstrating the benefit of increased dose of intervention, although our overview is cautious about drawing conclusions based on this evidence.
• Disagreement regarding evidence related to mirror therapy, with our overview concluding that there is evidence of benefit, andVeerbeek 2014concluding that there is no evidence of benefit;we recommend further exploration of RCT data related to mirror therapy.
• We have recommended an updated review and meta- analysis of evidence related to electrical stimulation;Veerbeek 2014reports the results of analysis of evidence related to electrical stimulation, suggesting that this intervention may provide beneficial effects.
41 Interventions for improving upper limb function after stroke (Review)
• Broad agreement regarding interventions for which low- quality evidence is currently available and further research is required.
A U T H O R S ’ C O N C L U S I O N S
Large numbers of overlapping reviews are related to interven- tions to improve upper limb function following stroke, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing a single, accessible, comprehensive document that brings together all relevant reviews (seeTable 2for a brief summary of results and implications). This overview should also play a key role in research prioritisation, ensuring effective use of resources, promoting col- laborative working toward shared priorities and avoiding duplica- tion of effort.
High-quality evidence related to the effectiveness of interventions to improve upper limb function is urgently needed, as is effective collaboration to support large, robust RCTs of interventions cur- rently used routinely within clinical practice. There is a particular need to establish evidence related to dose of interventions, as this has widespread implications for clinical practice, organisation of rehabilitation services and future research.
Implications for practice
A diverse range of interventions are aimed at improving upper limb function after stroke. In general, evidence is of low qual- ity and does not support clear clinical decisions. However, some moderate-quality evidence suggests that CIMT, mental practice, mirror therapy, interventions for sensory impairment, virtual re- ality and a relatively high dose of repetitive task practice may be effective interventions. These interventions should be considered for this patient group. However, clinical application of evidence will depend on specific details of an individual patient or setting, or both, and clinical decisions will require expert clinical reason- ing and judgement if available evidence is to be interpreted and applied effectively.
For interventions that are currently used routinely in clinical prac- tice, evidence is insufficient to support a change in clinical prac- tice, and we recommend that healthcare professionals continue to select and implement these interventions on the basis of individual patient assessment and expert clinical reasoning and judgement. However, research evidence is also available that is related to sev- eral interventions not yet widely used in routine clinical practice. These interventions include brain stimulation techniques (tDCS and rTMS) and robotic devices. On the basis of current evidence, we do not recommend the introduction of these emerging inter- ventions into clinical practice at this stage. High-quality evidence
suggests that tDCS does not provide benefit (or harm) in terms of ADL outcomes; therefore we do not currently recommend the in- troduction of tDCS into routine clinical practice. Although some moderate-quality evidence shows a beneficial effect of robotics, no evidence from systematic reviews suggests that this has been estab- lished in comparison with the same dose of conventional therapy; therefore we do not recommend the introduction of new robotic devices into routine clinical practice at this stage. Currently only low-quality evidence related to rTMS is available, and we sup- port the review authors in concluding that rTMS should not be introduced into clinical practice at this time. Further research is required before implications for practice related to these emerging therapies are apparent.
Implications for research
Further research is urgently required to establish high-quality ev- idence related to interventions to improve upper limb function after stroke. In particular, arising from (but not limited to) the results of this overview, we support recommendations for the fol- lowing.
• High-quality RCTs related to dose of intervention. The issue of dose of intervention is clearly central to establishment of meaningful high-quality evidence related to upper limb rehabilitation. Dose should always be carefully considered when primary and secondary research is planned and performed.
• Full-scale (phase III) RCTs to confirm the benefits of CIMT, mental practice, mirror therapy and virtual reality. • High-quality up-to-date reviews to synthesise current evidence on biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning interventions.
• High-quality RCTs to establish effectiveness of rTMS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment.
To ensure efficiency of future research, it is important that system- atic reviews are updated to incorporate new RCTs, and that fur- ther RCTs are planned with consideration of the evidence within relevant up-to-date systematic reviews and with knowledge of on- going RCTs. We urge researchers to ensure that details of ongoing RCTs are registered on relevant databases.
A C K N O W L E D G E M E N T S
We would like to thank Brenda Thomas for help in developing the search strategy.
Professor Phil Wiffen led a day workshop with review authors, during which we explored methods for assessment of quality of
evidence. Discussions at this workshop led to development of the objective criteria used to assign GRADE levels of evidence. We would like to acknowledge Phil’s key role in steering us in this direction and supporting the methodological decision making that we performed at this stage.
Pei Ling Choo kindly assisted us with translations and quality appraisal of a review published in Chinese.
We would like to thank all of the numerous review and protocol authors who took the time to respond to our requests for infor- mation about the status of their reviews, in particular Lucas Ro- drigues Nascimento, for providing in a timely manner data from his review.
We would like to thank Christine Fyfe, Heather Goodare, Tammy Hoffman, Kedar K Mate, Peter Sandercock, Brenda Thomas and Phil Wiffen for providing peer review comments on the overview.
R E F E R E N C E S
References to included reviews
Ada L, Foonghomcheay A, Canning CG. Supportive devices for preventing and treating subluxation of the shoulder after stroke.Cochrane Database of Systematic Reviews 2005, Issue
1. [DOI: 10.1002/14651858.CD003863.pub2] Barclay-Goddard RE, Stevenson TJ, Poluha W, Thalman L. Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke.Cochrane Database of Systematic Reviews 2011, Issue 5. [DOI: 10.1002/
14651858.CD005950.pub4]
Borisova Y, Bohannon RW. Positioning to prevent or reduce shoulder range of motion impairments after stroke: a meta- analysis. Clinical Rehabilitation 2009;23:681–6. [DOI:
10.1177/0269215509334841]
Bradt J, Magee WL, Dileo C, Wheeler BL, McGilloway E. Music therapy for acquired brain injury.Cochrane Database of Systematic Reviews 2010, Issue 7. [DOI: 10.1002/
14651858.CD006787.pub2]
Braun S, Kleynen M, Van Heel T, Kruithof N, Wade D, Beurskens A. The effects of mental practice in neurological rehabilitation: a systematic review and meta-analysis.
Frontiers in Human Neuroscience 2013;7:Article 390. [DOI:
10.3389/fnhum.2013.00390]
Cooke EV, Mares K, Clark A, Tallus RC, Pomeroy V. The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis. BMC Medicine 2010;8(60):Published
online Oct 13, 2010. [http://www.biomedcentral.com/ 1741–7015/8/60]
Corbetta D, Sirtori V, Moja L, Gatti R. Constraint- induced movement therapy in stroke patients: systematic review and meta-analysis.European Journal of Physical and Rehabilitation Medicine 2010;46(4):537–44.
Coupar F, Pollock A, van Wijck F, Morris J, Langhorne P. Simultaneous bilateral training for improving arm function after stroke.Cochrane Database of Systematic Reviews 2010,
Issue 4. [DOI: 10.1002/14651858.CD006432.pub2] Coupar F, Pollock A, Legg LA, Sackley C, van Vliet P. Home-based therapy programmes for upper limb functional recovery following stroke. Cochrane Database of Systematic Reviews 2012, Issue 5. [DOI: 10.1002/
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Demetrios M, Khan F, Turner-Stokes L, Brand C,
McSweeney S. Multidisciplinary rehabilitation following botulinum toxin and other focal intramuscular treatment for post-stroke spasticity. Cochrane Database of Systematic Reviews 2013, Issue 6. [DOI: 10.1002/
14651858.CD009689.pub2]
Diermayr G, Aviv H, Greisberger A. Effects of reach-to- grasp training using trunk restraint in individuals with hemiparesis post stroke: a systematic review. PROSPERO 17 December 2012. [CRD42012003464]
Doyle S, Bennett S, Fasoli SE, McKenna KT. Interventions for sensory impairment in the upper limb after stroke.
Cochrane Database of Systematic Reviews 2010, Issue 6.
[DOI: 10.1002/14651858.CD006331.pub2]
Elia AE, Filippini G, Calandrella D, Albanese A. Botulinum neurotoxins for post-stroke spasticity in adults: a systematic review. Movement Disorders 2009;24(6):801–12. [DOI:
10.1002/mds.22452]
Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. Cochrane Database of Systematic Reviews 2013, Issue 11. [DOI:
10.1002/14651858.CD009645]
Farmer SE, Durairaj V, Swain I, Pandyan AD. Assistive technologies: can they contribute to rehabilitation of the upper limb after stroke?.Archives of Physical Medicine and Rehabilitation 2014;95(5):968–85.
Foongchomchaey A, Ada L, Canning CG. Use of devices to prevent subluxation of the shoulder after stroke.
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[DOI: 10.1002/pri.3]
French B, Forster A, Langhorne P, Leathley MJ, McAdam J, Price CIM, et al. Repetitive task training for improving functional ability after stroke. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/
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French B, Leathley M, Sutton C, McAdam J, Thomas L, Forster A, et al. A systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness. Health Technology Assessment 2008; Vol. 12, issue 30.
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